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Published in final edited form as: Patient Educ Couns. 2023 Dec 13;120:108101. doi: 10.1016/j.pec.2023.108101

Understanding How Primary Care Providers Report Discussing Substance Use with Transgender and Gender Diverse Patients

Hill L Wolfe a,b, Gemmae M Fix c,d,e, Jaclyn MW Hughto f,g,h,i, Landon D Hughes j,k, Don Operario l, Scott E Hadland m,n, Jennifer Siegel o,p, Mari-Lynn Drainoni e,q,r
PMCID: PMC10842839  NIHMSID: NIHMS1952982  PMID: 38103396

Abstract

Objectives:

To explore how primary care providers report discussing substance use with transgender and gender diverse (TGD) adult patients within the context of discussing gender-affirming interventions.

Methods:

Between March and April 2022, in-depth, semi-structured qualitative interviews were conducted with 15 primary care providers who care for TGD patients in the Northeastern US. Thematic analysis was used to analyze interview data and identify patterns.

Results:

Two primary themes emerged among providers: 1) placing a focus on harm reduction, emphasizing reducing negative consequences of substance use and 2) using access to gender-affirming care interventions as an incentive for patients to change their substance use patterns.

Conclusions:

Focusing on harm reduction can emphasize reducing potential adverse consequences while working with TGD patients towards their gender-affirmation goals. Future research should explore varying approaches to discussing substance use with TGD patients, as well as the interpretation of gender-affirming clinical guidelines.

Practice Implications:

Findings from this study indicate a need for enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Investing in training efforts to improve gender-affirming care is critical for encouraging approaches that prioritize harm reduction and do not unnecessarily prevent access to gender-affirming care interventions.

Keywords: transgender and gender diverse, gender-affirming care, substance use, patient-provider communication, qualitative research

Introduction

Gender-affirming care refers to the delivery of healthcare that respects and affirms a patient’s gender identity [1]. A gender-affirming approach includes recognizing how transgender and gender diverse (TGD) patients describe their gender identity, expression, and anatomy (e.g., name, pronouns, anatomical terms, etc.) [1, 2]. Gender-affirming care includes facilitating access to gender-affirming care interventions [3]. Various types of providers may deliver gender-affirming interventions, such as endocrinologists who specialize in hormone therapy, surgeons trained in gender-affirming surgery, and mental health professionals who can offer therapy and assessments [2, 3]. Among providers, primary care providers often play a central role in managing gender-affirming care through prescribing and coordinating referrals to gender-affirming interventions [3].

A gender-affirming approach to care can extend to all clinical interactions and discussions, including routine discussions of health behaviors such as substance use that take place in the primary care setting. Specific gender-affirming care interventions can give rise to unique clinical considerations, particularly with substance use. For example, commonly used substances, such as tobacco, are associated with cardiovascular risk, which may also be further elevated by exogenous estrogen [4] and testosterone [5] administration. However, clinical guidelines for the care of TGD individuals in terms of substance use may read ambiguously. For example, multiple guidelines recommend clinicians should address tobacco use in patients undergoing gender-affirming hormone therapy [6–9], however, these guidelines do not expressly indicate that tobacco use is an absolute contraindication for hormone therapy. Nevertheless, providers may ask patients with cardiovascular risks to cease tobacco use before starting hormone therapy [10]. For individuals undergoing gender-affirming surgery, the use of tobacco and other substances can increase perioperative risk [11], which may prompt providers to address substance use with their TGD patients. Aside from tobacco, patients may use other substances, such as psychoactive drugs, or have heavy alcohol use that may also bring up clinical concerns regarding the effects on hormone therapy or surgical candidacy [10].

Limited training and lack of comfort among providers with discussing substance use [12, 13] and gender-affirming care [14–16] could result in inconsistent approaches in how providers address substance use with TGD patients [17]. Obstacles encountered among routine healthcare providers discussing substance use with patients, irrespective of their gender identity, include lack of addiction training, skepticism about substance use disorder treatment efficacy, and general discomfort discussing and providing patient education around tobacco, alcohol, and other drug use [12, 13]. Furthermore, just as obstacles arise when discussing substance use with patients, healthcare providers may similarly encounter challenges in providing affirming and supportive care to TGD patients due to the lack of emphasis on TGD health topics in medical training [14–16]. In part of the lacking education in TGD health, TGD individuals frequently encounter stigma and discrimination during healthcare encounters [18–21]. The largest survey of TGD adults revealed 28% reported experiencing verbal harassment in a healthcare setting while half reported needing to educate their providers about transgender healthcare [19]. The same survey also revealed that slightly over half of adults obtain gender-affirming care interventions from their routine care providers [19].

The potentially high number of primary care providers that may provide or coordinate gender-affirming interventions underscores the importance in understanding how primary care providers address substance use with their TGD patients. However, to our knowledge, no studies have explored how primary care providers approach substance use-related topics with TGD adult patients. To fill gaps in the literature, we sought to understand how primary care providers report discussing substance use with TGD adult patients within the context of discussing gender-affirming interventions.

2. Methods

2.1. Study Design and Framework

We conducted a qualitative study using semi-structured, in-depth interviews with primary care providers. The Consolidated criteria for REporting Qualitative Research (COREQ) Checklist was used to ensure methodological domains and this study’s findings were accounted for [22] (Supplementary File 1). This qualitative study was guided by the Framework to Improve Correctional Healthcare Providers’ Ability to Care for Transgender Patients [23]. The framework, which was originally developed in relation to the provision of care to TGD people in correctional settings, theorizes that a provider’s perception of their ability to care for TGD patients (i.e., self-efficacy) and the institutional support for caring for TGD patients (i.e., subjective norms) are important factors to understand how providers approach clinical and cultural elements of care for TGD patients [23]. The framework aided in the crafting of interview guide questions by ensuring we asked about providers’ perceptions of their experiences caring for TGD patients and the potential impact of their clinic environment and perceived support. During data analysis, the framework was instrumental in considering providers’ willingness to facilitate access to gender-affirming interventions.

2.1.1. Eligibility and Recruitment

Individuals were eligible to participate if they: 1) were a primary care provider with a Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), or Nurse Practitioner (NP) or similar credential, 2) possess clinical licensure in Massachusetts or Rhode Island, and 3) had knowingly ever provided care to at least one TGD adult patient. Providers were recruited via email from two provider lists used in previous studies engaging TGD community members and health providers [23–25]. Additionally, providers who work in LGBTQ+ health centers and/or were known in the community as providers that care for transgender patients were purposively sampled. In addition, healthcare clinics and transgender health consortia distributed the study’s recruitment materials through their networks via email and social media. Recruitment messaging invited providers to participate in a one-time interview and conveyed that our team is seeking their insights on enhancing routine health risk assessments for transgender and non-binary patients. Interested providers contacted the first author and were subsequently screened for eligibility by being asked if they met the eligibility criteria and were willing to undergo informed consent.

2.1.2. Data Collection

The semi-structured interview guide used “topical trajectories” [26] focusing on four topics: 1) provider and clinic background, 2) general experiences providing gender-affirming care, 3) how providers discuss and address substance use (use of tobacco and illicit drugs, and misuse of prescription medications) with TGD adult patients, and 4) implications for clinical practice (Supplementary File 2).

One-on-one interviews were conducted virtually on Zoom between March and April 2022 by the first author (HLW). Interviews were conducted until saturation was reached, which was discussed among the research team. Interview length was a mean of 32 minutes (range: 19-46 minutes). The first author, who is a trans male with experience leading qualitative interviews, conducted all interviews as part of a PhD dissertation. Prior to the interview, participants were informed of the research purpose and provided verbal consent. Participants also answered demographic questions about their race, ethnicity, gender identity, sex assigned at birth, sexual orientation, educational background (degree, specialty, training), years independently practicing medicine, and estimated number of TGD patients they ever cared for. Participants received a $25 electronic gift card for participating in the interview. The Boston Medical Center and Boston University Medical Campus Institutional Review Boards approved this research study.

2.2. Data Analysis

Each interview was recorded, transcribed, de-identified, and reviewed for accuracy. The transcripts were uploaded to NVivo 12 Plus for analysis [27] and analyzed using a deductive and inductive approach [28] by the PI (HLW) and an additional analyst (LDH). The PI is trained in health services research and implementation science and the other analyst has a background in health behavior and social epidemiology. Both have expertise in LGBTQ+ health and have used qualitative methods with TGD populations in previous work. First, deductive codes were generated. A codebook was created using a priori coding categories based on the guiding theoretical framework [23]. The transcripts were then coded inductively (codes derived from the data). As inductive codes were created, they were added to the codebook. Both coders initially double-coded two transcripts to ensure consistency in coding application and to discuss newly added codes. After reaching consensus, the remaining transcripts were coded independently. After coding was complete, thematic analysis was used to identify how providers described their methods discussed substance use with TGD patients [28–30]. Themes were identified by comparing and analyzing the relationships between codes [29, 30]. Descriptive statistics of the demographic data was analyzed using Microsoft Excel [31].

3. Results

3.1. Sample Characteristics

A description of the study sample is presented in Table 1. In total, 15 primary care providers participated in semi-structured, qualitative interviews. Almost 75% (n=11) were physicians, and the majority specialized in internal medicine. Although we did not explicitly recruit providers who were actively practicing medicine, the providers who participated in our study were all currently caring for patients. Providers described providing a range of gender-affirming care, including but not limited to sexual health services, hormone therapy, medical support for pre- and post-operative surgical care, and providing referrals to other transition-related services (e.g., vocal therapy, psychiatric services). All but two providers had experience initiating or managing hormone therapy. The estimated number of TGD patients that providers had ever cared for ranged from 3 to 1,000 patients (median=100 patients). Two participants identified as transgender or a related gender identity, and almost half (n=7) identified with a sexual orientation other than heterosexual (e.g., gay, lesbian, queer).

Table 1.

Demographic Characteristics of Primary Care Providers (n=15)

Characteristic n (%)
Medical Background
Provider Type
 Physician (MD/DO) 11 (73.3)
 Nurse Practitioner (NP) 4 (26.7)
Specialty
 Addiction 2 (13.3)
 Family Medicine 4 (26.7)
 Gerontology 1 (6.7)
 Infectious Disease 4 (26.7)
 Internal Medicine 8 (53.3)
Mean Range
Years Practicing 12.71 2-39
Number of TGD Patients (Median) 100 3-1,000
Social Demographics
Race
 Asian 2 (13.3)
 Black 1 (6.7)
 White 11 (73.3)
 Other 3 (10.0)
Ethnicity
  Hispanic 2 (13.3)
  Non-Hispanic 13 (86.7)
Sex Assigned at Birth
  Female 10 (66.7)
  Male 5 (33.3)
Gender Identity
  Cisgender 13 (86.7)
  Transgender, non-binary, or Another gender minority 2 (13.3)
Sexual Orientation
  Lesbian/Gay 5 (33.3)
  Bisexual 1 (6.7)
  Heterosexual 8 (53.3)
  Queer, Pansexual, or Another sexual orientation 1 £(6.7)
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Note. Years Practicing represents time practicing independently without supervision. Number of TGD Patients represents estimated guess of known patients who are transgender or gender diverse that providers have cared for. Specialty and Race are not mutually exclusive categories.

3.2. Overview and Themes

Providers described their approaches to substance use in the context of discussing gender-affirming interventions. Two primary themes emerged: First, some providers reported placing a focus on harm reduction, emphasizing both reducing negative consequences of substance use and meeting patients where they are to facilitate discussions about substance use in primary care settings. Providers who used a harm reduction approach would communicate upfront to patients that substance use would not deter access to gender-affirming care interventions. Second, other providers reported using access to gender-affirming care interventions as an incentive for patients to change their substance use patterns. This approach entailed behaviors like instructing patients to reduce or abstain from use to receive hormone therapy. Each theme is accompanied by quotes from participants with additional illustrative quotes presented in Table 2.

Table 2.

Additional participant quotes organized by theme

Theme Participant Quote
Harm Reduction Provider 310, MD Our approach has always been we’re not going to withhold access to therapy for someone, but we just need to have to make sure we’re having an informed conversation and offer things like smoking cessation or try to help mitigate some of those risks. So, I my sense is that people feel comfortable disclosing all of those things. Because they know our goal is to really try to meet people where they’re at in terms of alcohol or other substance use.
Provider 304, NP You discuss the risk. And yeah, there’s really no guideline for [substance use]. So, I mean, you’re encouraged to sort of do risk reduction… that’s what we try to do as best… because it’s difficult to find some guidelines.
Provider 307, NP I think that opportunities to talk about harm reduction is where I’ve had the most opportunity to dig in… I had a patient one time who had an abscess on her arm from using intravenous substances. And she was still using it or whatever and I said, ‘make sure you’re not injecting into that area. Try injecting into other areas.’ And she just laughed. And we’d known each other for a couple years at this point. Just, I think they’re floored when you’re just accepting of the fact that I know you’re going to use IV substances later on today. Try to do it in the safest way. Sometimes I think those opportunities that you can educate about safety which is fantastic and just acknowledge that this is okay.
Using gender-affirming interventions as an incentive Provider 309, MD Substance use and mental health are often held up as, ‘I’m not comfortable with doing this, where you make me nervous as a patient. There’s more risk of that outcomes. I don’t know that I want to get involved or start this pathway.’
Provider 316, MD I think unfortunately there’s still a mentality, and this is not just in the trans non-binary community, it’s really sort of pervasive through medicine that if people aren’t willing to ‘accept’ our treatment for substance use disorder, then we shouldn’t be willing to go out [and] offer other treatments to that individual. I think that’s a really sort of antiquated and perhaps a backwards way of viewing this that only perpetuates the cycle of stigma and distrust and inability to access healthcare.
Provider 302, MD The provider might say, ‘oh, well there’s a contraindication. I’m worried about if we start testosterone and you’re regularly using cocaine that you’re going to have a stroke or something, so I’m not going to do it.’
Provider 305, MD [Name of provider] is one of these people who he’s quite charismatic and he uses his big personality to make strong points about habits: ‘And look, if you keep smoking, I’m not going to prescribe these hormones. You got to stop because these synergistically promote cardiovascular diseases.’
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3.2.1. Using harm reduction to reduce negative consequences of substance use

Most providers shared the importance of communicating harm reduction. These providers explicitly used the term “harm reduction” to describe communicating to patients their approach focused on reducing negative consequences of substance use and acknowledging realistic challenges with behavior change. By acknowledging the circumstances of each patient in relation to their substance use, one provider shared: “I think those harm reduction conversations have the opportunity to really bond and create rapport with patients” (Provider 307, NP). Providers discussed having open and honest dialogue to understand a patient’s circumstances and their potential health goals, such as receiving gender-affirming surgery. This included addressing patients’ gender-affirmation goals by providing patient education on mitigating risk. For example, for patients seeking hormone therapy who use tobacco products, cocaine, or other substances, the route of administration or type of hormone may be adjusted to reduce the risk of complications:

What I tell patients is that smoking is not a contraindication for estrogen therapy and we can potentially select other options or mechanisms of delivery from a harm reduction standpoint— whether that’s transdermal estrogen for folks who smoke tobacco or whether it’s through injection or not. That way, I just make it clear that it’s not necessarily a contraindication. But through harm reduction, we can reduce the risk of cardiovascular events by using other forms of estrogen delivery for example (Provider 315, MD).

In some instances, providers described working with colleagues to ensure a harm reduction approach was used with TGD patients and gender-affirming care interventions are not unnecessarily withheld. For example, one provider described working with the substance use clinic in their medical center to co-manage patients and provide TGD health education about the effective management of care with TGD patients:

There are a number of patients that I co-manage with our substance use clinic and we’ve done a lot of education with that program about not using gender-affirming care as a ‘carrot or a stick’ when dealing with substance use. Meaning, I should not be setting up a system where someone can only receive hormone therapy if they also agree to show up for Suboxone, monitoring or methadone prescribing or whatever it might be (Provider 316, MD).

In addition, to ensure that patients were well-informed and prepared to potentially seek support for substance use, several providers advised patients about the possibility of encountering more stringent expectations from other clinicians. One provider shared how they inform their patients about potential requirements from other clinicians and empower patients to decide on the course of action they wish to take in addressing these expectations:

I’m like, ‘hey, I’m quite flexible. I have wide boundaries but not everybody in the world has that flexibility, especially when it comes to surgeries. The surgeon is often much more black-and-white and you may encounter a roadblock. So, you can work on it with me now with the team we’re going to build or you can work on it in order later to get surgeries potentially.’ And I find that kind of brokering and making the patient sort of increase their agency in this because it’s a step towards one of their goals (Provider 305, MD).

3.2.2. Using gender-affirming interventions as an incentive to change substance use patterns

Some providers shared that when informing patients about the harm of substance use, they also communicate to patients that gender-affirming care interventions, especially hormone therapy, will be withheld if patients use certain substances or have a substance use disorder. A few providers discussed how gender-affirming care interventions could serve as “motivation” for TGD patients to reduce or abstain from substance use. Similarly, a few providers shared that they required patients to agree to substance use disorder treatment prior to receiving any gender-affirming care interventions, for example: “If people aren’t willing to ‘accept’ our treatment for substance use disorder, then we shouldn’t be willing to go out [and] offer other treatments to that individual” (Provider 303, MD).

In several cases, tobacco use, and occasionally cocaine use, was commonly used as an example of when providers would withhold gender-affirming care interventions due to clinical risks tied to strokes, venous thrombosis, or other cardiovascular events. For example, one provider shared their struggle with caring for TGD patients using both hormone therapy and tobacco:

I think this is a really hard thing as a provider who my goal is always to do no harm, right? And so, I really struggle sometimes with, ‘Am I doing more harm by withholding, in this situation, the hormone replacement therapy? Or am I doing more harm by allowing it knowing that there could be risks associated with cardiovascular health if the patient is using tobacco and taking hormone replacement therapy?’ (Provider 308, NP)

While some providers viewed a patient’s tobacco or cocaine usage as a reason to completely withhold hormone therapy, other providers often referred to their colleagues who held this stance. In talking about their colleague, one provider explained:

There are definitely [providers] out there that have a much more restrictive approach to hormones and who might read into the general guidelines which states that mental health concerns should be reasonably well controlled before you initiate hormone therapy and might read into that as a substance use disorder needs to be in remission before we can prescribe it. Definitely there are providers that will do that. That’s not my practice though (Provider 313, MD).

On multiple occasions, providers shared that they did not use this approach themselves. Rather, providers shared that their colleagues in other clinics, including those who had previously trained them, employed this tactic. When referring to their colleagues, a few providers referred to this approach as the “carrot or a stick” or “punishment or reward” method.

4. Discussion and Conclusion

Providers who adopted a harm reduction approach to reduce negative consequences of substance use emphasized to patients that their substance use would not hinder or compromise their access to gender-affirming interventions. For these providers, harm reduction generally entailed reducing negative consequences for patients and “meeting patients where they’re at.” Prior work has emphasized that the respectful delivery of care is an important component to harm reduction for TGD patients given their likely histories of stigmatization from prior healthcare encounters [32, 33]. In instances where patients disclosed unhealthy substance use to their providers and were seeking gender-affirming care interventions, providers facilitated access by giving patients the ultimate decision-making authority about using hormone therapy or proceeding onward with plans for surgery. Additionally, providers would often offer ways to reduce potential risks of complications by tailoring treatment plans. In these scenarios, providers sought to balance reducing potential adverse consequences while working with patients towards their gender-affirmation goals.

Other providers described themselves or colleagues as using incentivizing techniques with gender-affirming care interventions to influence TGD patients’ substance use patterns. Using a punishment-and-reward method with gender-affirming care interventions to incite a desired behavior has been documented previously [34]. For example, a qualitative study of correctional healthcare providers from the Northeastern US revealed hormone therapy was at times withheld from incarcerated TGD people as punishment for “acting up” [34]. For other providers, the potential for adverse health outcomes resulting from the interaction of substance use and certain gender-affirming care interventions prompted them to apply strict requirements for providing hormone therapy or surgical letters. Prior work has found that providers who rigidly apply gender-affirming care guidelines aim to minimize uncertainty [35]. In our study, providers who described using gender-affirming care interventions as an incentive for substance use reduction or cessation self-reported having knowledge gaps in TGD health and belonging to clinics that did not have training in gender-affirming care. These findings highlight the importance of investing in interventions that increase providers’ confidence in their capacity to care for TGD patients while having a supportive clinic environment.

These findings have clinical and policy implications for effectively delivering gender-affirming care to TGD adults who use substances. A lack of clarity in existing guidelines around aligning hormone therapy with substance use may be one reason why providers resorted to using gender-affirming care interventions as an incentive to manage their substance use. For example, guidelines from the University of California, San Francisco’s Gender Affirming Health Program recommends “stabilizing co-occurring mental illness prior to initiation of hormones, but in some cases the medical treatment of gender dysphoria is best done simultaneously with treatment of mental illness and substance use disorders ” [36]. Additionally, several guidelines recommend clinicians should attend to tobacco use or encourage cessation for cardiovascular risk purposes when using hormone therapy [6–9]. However, guidelines do not explicitly state that tobacco use alone is an absolute contraindication to hormone therapy. Nevertheless, due to the potential ambiguity surrounding this, providers may restrict access to gender-affirming care interventions.

Given the variation in patients’ health status and transition-related goals, guidelines from both the World Professional Association for Transgender Health (WPATH) and Fenway Health specifically call for a flexible application [6, 8, 9]. Since data were collected for this study in early 2022, the WPATH released new Standards of Care (version 8) updated from 10 years prior. Their most recent guidelines unequivocally state: “Addressing mental illness and substance use disorders is important but should not be a barrier to transition-related care.” Hence, simply the presence of a substance use disorder should not undermine access to gender-affirming care interventions. Ensuring widespread dissemination of the current WPATH guidelines, as well as updates to other clinical recommendations, is paramount to enhancing discussions about substance use between providers and TGD patients. Furthermore, the development and dissemination of validated tools for substance use screening, assessment, and shared decision making to help guide treatment decisions for TGD patients is imperative.

Requiring patients to abstain or reduce their substance use before having access to gender-affirming care interventions may have unintended adverse health consequences. Prior studies have found that TGD-related discrimination in healthcare settings and being denied care are associated with increased substance use [21, 37]. Meanwhile, other work has found that having access to hormone therapy may actually reduce substance use [38]. Thus, being made aware of the complexities between substance use and access to gender-affirming care interventions is warranted for providers and policymakers alike.

4.1. Limitations

This study is not without limitations. First, the providers we spoke with were overwhelmingly white and practiced primary care in Massachusetts and Rhode Island—states that are recognized for their progressive policies and practices. However, there was heterogeneity within the sample in years practicing medicine and the approximate number of TGD patients ever cared for, giving a range and depth to experiences with TGD patients. Second, we are lacking the perspectives of clinicians with different training backgrounds, such as endocrinologists, clinical pharmacists, and other providers with prescribing authority who also have a role in the management of gender-affirming hormone therapy and other medical interventions for TGD patients. Third, we relied solely on clinicians’ self-report; incorporating direct observation of clinical encounters would provide stronger insight into how providers address patient care. Lastly, since this is a qualitative study, the findings may not be generalizable to the broader population.

4.2. Conclusion

Through in-depth qualitative interviews, we explored how providers reported discussing substance use with TGD adult patients within the context of discussing gender-affirming interventions. Findings from this study carry implications for policy and clinical practice, including integrating substance use care with gender-affirming care in addition to enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Our work suggests that investing in training efforts [23–25] is critical for encouraging approaches that prioritize harm reduction and not unnecessarily preventing access to gender-affirming care interventions. Future research should further explore the variation in approaches to discussing substance use with TGD patients, as well as the interpretation of gender-affirming clinical guidelines, particularly concerning the consideration of patients’ other medical and social histories.

4.3. Practice Implications

Findings from this study indicate a need for better understanding and implementation of gender-affirming care guidelines during clinical encounters with TGD adults who use substances. Our work indicates that various interpretations of guidelines may potentially lead to unwarranted restrictions on access to gender-affirming care interventions. Investing in training efforts to increase the capacity for improved gender-affirming care is critical for encouraging approaches that prioritize harm reduction and honor patients’ gender-affirmation goals.

Supplementary Material

1
2

Highlights.

  • Many transgender and gender diverse (TGD) patients face barriers to healthcare.

  • Lack of comfort and training can result in varying substance use communication.

  • Providers were unsure about potential contraindications related to substance use.

  • Incentive-based and harm reduction approaches were used with TGD patients.

  • Investing in training in gender-affirming care guidelines is critical.

Acknowledgments:

We extend our sincere gratitude and appreciation to the providers for their invaluable contributions to our study.

Role of Funding Sources

This work was supported by the National Institute on Drug Abuse [grant number T32-DA041898 to H.L.W.]. J.M.W.H. is supported by COBRE on Opioids and Overdose funded by the National Institute of General Medical Sciences of the National Institutes of Health under Grant Number P20GM125507. L.D.H. is supported by the Yerby Fellowship at Harvard T.H. Chan School of Public Health. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the National Institutes of Health, Department of Veterans Affairs, or the United States Government.

Footnotes

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Contributors and CRediT Author Statement

Hill L. Wolfe: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Visualization; Gemmae M. Fix: Conceptualization, Methodology, Writing - Original Draft, Supervision; Jaclyn M.W. Hughto: Conceptualization, Methodology, Writing - Original Draft, Supervision; Landon D. Hughes: Formal analysis, Writing – Review & Editing; Don Operario: Conceptualization, Writing – Review & Editing; Scott E. Hadland: Conceptualization, Writing – Review & Editing; Jennifer Siegel: Conceptualization, Methodology, Writing - Original Draft, Supervision; Mari-Lynn Drainoni: Conceptualization, Methodology, Writing - Original Draft, Supervision. Jennifer Siegel serves as the second senior author. All authors contributed to and have approved the final manuscript.

Declarations of Competing Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data Availability:

The data that has been used is confidential. The underlying data for this study consists of in-depth, qualitative interviews with providers from the Northeastern US. It is not possible to create a minimal dataset with these data. Due to the sensitive nature of these interviews, the datasets created and analyzed during this study are not publicly available to protect participant privacy.

References

  • [1].Reisner SL, Radix A, Deutsch MB, Integrated and Gender-Affirming Transgender Clinical Care and Research, J Acquir Immune Defic Syndr 72 Suppl 3 (2016) S235–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [2].Bhatt N, Cannella J, Gentile JP, Gender-affirming Care for Transgender Patients, Innov Clin Neurosci 19(4-6) (2022) 23–32. [PMC free article] [PubMed] [Google Scholar]
  • [3].Cosio I, Goldman L, MacKenzie M, Townsend M, Gender-affirming primary care, BC Med J 61(1) (2022) 20–22. [Google Scholar]
  • [4].Getahun D, Nash R, Flanders WD, Baird TC, Becerra-Culqui TA, Cromwell L, Hunkeler E, Lash TL, Millman A, Quinn VP, Robinson B, Roblin D, Silverberg MJ, Safer J, Slovis J, Tangpricha V, Goodman M, Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study, Ann Intern Med 169 (2018) 205–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [5].Irwig MS, Testosterone therapy for transgender men, Lancet Diabetes Endocrinol 5 (2017) 301–311. [DOI] [PubMed] [Google Scholar]
  • [6].Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfaefflin F, Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale A, Winter S, Whittle S, Wylie KR, Zucker K, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7, Int J Transgender Health 13 (2012) 165–232. [Google Scholar]
  • [7].Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T’Sjoen GG, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, J Clin Endocr 102 (2017) 3869–3903. [DOI] [PubMed] [Google Scholar]
  • [8].Thompson J, Hopwood R, deNormand S, Cavanaugh T, Medical Care of Trans and Gender Diverse Adults, Fenway Health, Boston, MA, 2021. [Google Scholar]
  • [9].Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D’Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, Amand C. St., Steensma TD, Strang JF, Taylor GB, Tilleman K, T’Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J, Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, Int J Transgend 23 (2022) S1–S259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [10].Informed Consent for Feminizing Hormone Therapy. https://fenwayhealth.org/documents/medical/transgender-resources/Fenway_Health_Consent_Form_for_Feminizing_Therapy.pdf. (Accessed July 6, 2023.
  • [11].Hardacker CT, Chyten-Brennan J, Komar A, A Provider’s Guide to Gender-Affirming Surgeries, in: Hardacker C, Ducheny K, Houlberg M (Eds.), Transgender Physiology, Anatomy, and Aging, Springer, Cham: 2019, pp. 37–60. [Google Scholar]
  • [12].Yoast RA, Wilford BB, Hayashi SW, Encouraging physicians to screen for and intervene in substance use disorders: obstacles and strategies for change, J Addict Dis 27 (2008) 77–97. [DOI] [PubMed] [Google Scholar]
  • [13].Winters KC, Kaminer Y, Screening and assessing adolescent substance use disorders in clinical populations, J Am Acad Child Adolesc Psychiatry 47 (2008) 740–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [14].Korpaisarn S, Safer JD, Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons, Rev Endocr Metab Disord 19 (2018) 271–275. [DOI] [PubMed] [Google Scholar]
  • [15].Park JA, Safer JD, Clinical Exposure to Transgender Medicine Improves Students’ Preparedness Above Levels Seen with Didactic Teaching Alone: A Key Addition to the Boston University Model for Teaching Transgender Healthcare, Transgender Health 3 (2018) 10–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [16].White W, Brenman S, Paradis E, Goldsmith ES, Lunn MR, Obedin-Maliver J, Stewart L, Tran E, Wells M, Chamberlain LJ, Fetterman DM, Garcia G, Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students’ Preparedness and Comfort, Teach Learn Med 27 (2015) 254–63. [DOI] [PubMed] [Google Scholar]
  • [17].Sun CJ, Doran KM, Sevelius JM, Bailey SR, A Qualitative Examination of Tobacco Use and Smoking Cessation Among Gender Minority Adults, Ann Behav Med 57 (2023) 530–540. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [18].White Hughto JM, Reisner SL, Pachankis JE, Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions, Soc Sci Med 147:222–231 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [19].James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M, The report of the 2015 U.S. Transgender Survey, Washington, DC. National Center for Transgender Equality, 2016. [Google Scholar]
  • [20].Rodriguez A, Agardh A, Asamoah BO, Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens, Archives of Sexual Behavior 47(4) (2018) 973–985. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [21].Reisner SL, Pardo ST, Gamarel KE, White Hughto JM, Pardee DJ, Keo-Meier CL, Substance Use to Cope with Stigma in Healthcare Among U.S. Female-to-Male Trans Masculine Adults, LGBT Health 2 (2015) 324–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [22].Tong A, Sainsbury P, Craig J, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, International Journal for Quality in Health Care 19(6) (2007) 349–57. [DOI] [PubMed] [Google Scholar]
  • [23].Hughto JMW, Clark KA, Altice FL, Reisner SL, Kershaw TS, Pachankis JE, Improving correctional healthcare providers’ ability to care for transgender patients: Development and evaluation of a theory-driven cultural and clinical competence intervention, Soc Sci Med 195 (2017) 159–169. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [24].White JM, Mimiaga MJ, Krakower DS, Mayer KH, Evolution of Massachusetts physician attitudes, knowledge, and experience regarding the use of antiretrovirals for HIV prevention, AIDS Patient Care STDS 26 (2012) 395–405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [25].White Hughto JM, Clark KA, Pachankis JE, Correlates of transgender cultural and clinical competency among healthcare providers in Massachusetts, 145th American Public Health Association Conference, Atlanta, GA, 2017. [Google Scholar]
  • [26].Cohen D, Crabtree B, Qualitative Research Guidelines Project, 2006. http://www.qualres.org/HomeEval-3664.html. (Accessed November 4, 2020.
  • [27].NVivo, 2018. https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home.
  • [28].Fereday J, Muir-Cochrane E, Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development, International Journal of Qualitative Methods 5(1) (2016) 80–92. [Google Scholar]
  • [29].Kiger ME, Varpio L, Thematic analysis of qualitative data: AMEE Guide No. 131, Medical Teacher 42 (2020) 846–854. [DOI] [PubMed] [Google Scholar]
  • [30].Braun V, Clarke V, Using Thematic Analysis in Psychology, Qual Res Psychol 3 (2006) 77–101. [Google Scholar]
  • [31].Microsoft Excel, 2021. https://office.microsoft.com/excel.
  • [32].Dietz E, Halem J, How Should Physicians Refer When Referral Options Are Limited for Transgender Patients?, AMA J Ethics 18 (2016) 1070–1080. [DOI] [PubMed] [Google Scholar]
  • [33].Reback CJ, Lombardi EL, Transgender and HIV, in: Bockting W, Kirk S (Eds.), Routledge; 2001. [Google Scholar]
  • [34].Clark KA, White Hughto JM, Pachankis JE, “What’s the right thing to do?” Correctional healthcare providers’ knowledge, attitudes and experiences caring for transgender inmates, Soc Sci Med 193 (2017) 80–89. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [35].Shuster SM, Uncertain Expertise and the Limitations of Clinical Guidelines in Transgender Healthcare, J Health Soc Behav 57 (2016) 319–32. [DOI] [PubMed] [Google Scholar]
  • [36].Deutsch M, UCSF Gender Affirming Health Program, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, 2016. [Google Scholar]
  • [37].Romanelli M, Lu W, Lindsey MA, Examining Mechanisms and Moderators of the Relationship Between Discriminatory Health Care Encounters and Attempted Suicide Among U.S. Transgender Help-Seekers, Adm Policy Ment 45 (2018) 831–849. [DOI] [PubMed] [Google Scholar]
  • [38].Heylens G, Verroken C, De Cock S, T’Sjoen G, De Cuypere G, Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder, JSM 11 (2014) 119–26. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1952982-supplement-1.pdf (508.8KB, pdf)
2
NIHMS1952982-supplement-2.docx (21.2KB, docx)

Data Availability Statement

The data that has been used is confidential. The underlying data for this study consists of in-depth, qualitative interviews with providers from the Northeastern US. It is not possible to create a minimal dataset with these data. Due to the sensitive nature of these interviews, the datasets created and analyzed during this study are not publicly available to protect participant privacy.

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